Increasing irritability with sudden onset of flaccid weakness

Spontaneous spinal epidural hematoma (SSEH), is a rare and potentially fatal condition that responds favorably to early surgical intervention and should be considered in the differential diagnosis of spinal cord compression. There are few reported cases in children. We present a case of spontaneous spinal epidural hematoma in an 18-month-old child and review the literature.     

Acute nontraumatic spinal epidural hematomas. An important differential diagnosis in spinal emergencies

STUDY DESIGN: The clinical data of five patients with spontaneous spinal epidural hematoma (SSEH) were reviewed. OBJECTIVES: To assess the clinical outcome of patients with SSEH after surgical decompression. SUMMARY OF BACKGROUND DATA: The outcome in SSEH is essentially determined by the timing of the operation. Therefore, early and precise diagnosis is necessary. METHODS: A retrospective analysis of five patients with SSEH was performed. The clinical data were stratified according to the Frankel Score. Special interest was given to the relevance of rapid and exact diagnosis and immediate therapeutic intervention. RESULTS: Diagnosis of SSEH was established preoperatively by means of computed tomography (one case) or magnetic resonance imaging (three patients) and intraoperatively in one case. Lumbar myelography had been false negative in one patient, computed tomography false-negative in two patients. Surgical decompression was performed in four patients within 24 hours after the onset of symptoms. Favorable postoperative functional results were found only in one patient whose symptoms had been present for less than 12 hours and in the case of an incomplete cauda equina syndrome. CONCLUSIONS: The results of the current series demonstrate both the superiority of magnetic resonance imaging for diagnosis of SSEH as well as the necessity of early decompressive surgery in cases of sensorimotor paralysis after SSEH.     

Pitfalls of hyperfractionation: theoretical considerations of effect of repair time on late radiation damage]

We conducted a 3-year Taiwan-wide hospital-based survey of invasive Haemophilus influenzae infections in children less than 15 years of age. From January 1992 to December 1994, 105 cases (57 boys, 48 girls) were reported. Seventy-three patients (69.5%) had meningitis and 32 patients had other diseases (12 pneumonia, 10 sepsis, 7 cellulitis, 3 arthritis). Fourteen patients (13%) died, all of whom had meningitis or sepsis. Among the 63 patients who survived meningitis, 17 (27%) had neurologic sequelae and eight (47%) had hearing impairment. The number of cases of H. influenzae meningitis (30%) and other H. influenzae diseases (29%) peaked in children between 6 and 12 months of age. Patients with invasive infections (82%) and meningitis (73%) were younger than 24 months of age. Only 12 patients (11%) were older than 5 years of age and four had underlying diseases. The annual incidence of invasive H. influenzae infections in children less than 5 years old was 1.9 per 100,000 per year. During the same period a survey of purulent meningitis in children younger than 15 years of age was also conducted in 20 hospitals. A total of 198 patients, in whom the causative organisms were identified, were included; 94 patients were 2 months of age or under and the most frequent pathogen was group B streptococci (35 cases, 37%). Among the 104 patients who were older than 2 months of age, H. influenzae was the leading cause (38 cases, 37%). In conclusion, invasive H. influenzae type b (Hib) diseases exist in Taiwan but have an incidence lower than in Western countries. Hib meningitis is still the most common cause of purulent meningitis in children in Taiwan and is an important cause of mortality and morbidity. Continuous active surveillance of invasive H. influenzae infections is suggested to determine the best time to introduce an Hib conjugate vaccine in Taiwan.     

Superior outcomes in pediatric renal transplantation

BACKGROUND: Nationally, results of renal transplantation in children, particularly in small children, are inferior to those obtained in adults. OBJECTIVE: To determine factors important for success in renal transplantation in children. DESIGN: Results of 108 consecutive renal transplantations performed in patients aged 7 months to 18 years were reviewed and compared with those reported by the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS), the national registry. RESULTS: One-, 2-, and 3-year graft survival rates (+/-SE) were 99% +/- 1%, 95% +/- 3%, and 93% +/- 4%, respectively, for living donor grafts and 97% +/- 3%, 92% +/- 6%, and 92% +/- 6%, respectively, for cadaver grafts. Incidence of acute rejection was half that reported by NAPRTCS. There were no graft losses for technical reasons (19% in NAPRTCS). Twelve percent of patients were younger than 2 years (6% in NAPRTCS); 17% were 2 to 5 years old (16% in NAPRTCS). Most small children received an adult-sized kidney. Ninety-three percent of recipients weighing 15 kg or less received postoperative mechanical ventilation assistance to optimize fluid resuscitation and perfusion of adult-sized kidneys. Structural abnormalities of the urinary tract were present in 53.7% of the patients (48.5% in NAPRTCS; adults, 5.3%). Nephroureterectomy was required in 38 children; in 27 (71%) of them, it was performed at the time of transplant surgery. CONCLUSIONS: Excellent results can be obtained in pediatric renal transplantation by strict adherence to surgical detail, tight immunosuppressive management, aggressive fluid management in the small child, and careful integration of urologic and transplant surgery.     

Epidural spinal infection. Variability of clinical and magnetic resonance imaging findings

STUDY DESIGN: This study evaluates the magnetic resonance characteristics of spinal epidural abscesses and their associated disc space infections. OBJECTIVES: The results were correlated with history, clinical, and laboratory findings to provide guidelines for early and appropriate diagnosis of epidural spinal infections. SUMMARY OF BACKGROUND DATA: Imaging signs of spinal infections have been reported before, but not with special attention to early clinical and imaging findings. METHODS: Thirteen patients (10 men, 3 women; age range, 32-64 years) with progressive sensorimotor deficit were studied. All patients had a neurologic examination after admission and a magnetic resonance imaging scan done within the first 48 hours. In all cases, T1-weighted images before and after administration of gadolinium were obtained. T2-weighted images were acquired in eight cases as well. Ten patients subsequently underwent open surgery; in three cases, a percutaneous biopsy and drainage was performed. RESULTS: Cervical discitis was found in five patients, and thoracic discitis was seen in another five cases. Three patients had an epidural infection without a concomitant discitis. Neurologic and clinical findings varied considerably. Despite clinical signs of spinal cord involvement, a spinal cord lesion was demonstrated only once. Signal change in T2-weighted images may be the first sign of disc space infection. Because a neurologic deficit may occur before any change is visible, follow-up examinations may be required if epidural infection is suspected on clinical grounds. CONCLUSIONS: Magnetic resonance imaging is the appropriate method for diagnostic work-up of progressive neurologic deficit resulting from epidural infection.     

Neurologic complications after placement of cerebrospinal fluid drainage catheters and needles in anesthetized patients: implications for regional anesthesia. Mayo Perioperative Outcomes Group

Subarachnoid or epidural needle placement in an anesthetized patient is controversial because general anesthesia and muscle relaxation may mask neural trauma. However, placement of a needle or catheter in the subarachnoid space for the purpose of cerebral spinal fluid (CSF) drainage is frequently performed in anesthetized patients undergoing neurosurgery. The records from 530 consecutive transsphenoidal surgeries performed with lumbar CSF drainage were reviewed to determine the types of neurologic complications attributable to spinal drainage and their rates of occurrence. All patients were anesthetized during CSF drain placement. A 19-gauge malleable needle was placed in 473 (89%) patients. Subarachnoid catheters (20- or 16-gauge catheters placed via 18- or 14-gauge epidural needles, respectively) were placed in 17 (3%) patients. In 40 (8%) patients, the type of drain was unspecified. No new neurologic deficits attributable to spinal drain insertion were detected in the immediate postoperative period or within 1 yr of surgery. Thirteen patients developed postdural puncture headache (2.5%, exact 95% confidence interval 1.3%-4.2%); seven required epidural blood patch (1.3%, 0.5%-2.7%). The low incidence (0%, 0.0%-0.7%) of neurologic injury from spinal drain insertion in anesthetized patients from this study is similar to the incidence of neurologic complications historically reported for both CSF drain insertion and spinal anesthesia. Implications: The performance of regional anesthesia in an anesthetized patient is controversial due to the possibility of unrecognized nerve injury. We report no cases of nerve injury caused by the placement of cerebrospinal fluid drainage needles and catheters in 530 anesthetized patients undergoing neurosurgery.     

Increased erythrocyte deformability in fetal erythropoiesis and in erythrocytes deficient in glucose-6-phosphate dehydrogenase and other glycolytic enzymes

We evaluated the results of an excision of the radial head in 25 patients (27 operated-on elbows) younger than 18 years with stiff painful radiocapitellar joints. The mean age was 14.2 years (range, 4.6-17.8 years) with average follow-up of 7.8 years. Analysis of the results with a postoperative elbow score revealed excellent or good results in 19 of the 27 elbows of patients. Skeletal maturity of the patient did not alter the results based on the rating scale. Revision surgery to remove appositional bone growth was needed in six of the 12 posttraumatic cases and one of 15 developmental elbows. Cubitus valgus, wrist pain, and ulnar neuropathy were not clinical problems at follow-up examination. Excision of the radial head was beneficial for 70% of patients younger than 18 years with stiff, painful radiocapitellar joints. Results were not improved in patients who had reached skeletal maturity.     

Clinicopathologic characteristics of replication error-positive gastric carcinoma

OBJECTIVES: To determine the incidence of skull fracture (SF) and intracranial injury (ICA) among children younger than 2 years evaluated in a pediatric emergency department for head trauma; whether historical features and/or physical findings are predictive of injury type; and whether clinical criteria could allow a selective approach to radiographic imaging. DESIGN: Retrospective medical record review. SETTING: Tertiary pediatric emergency department. PATIENTS: Case series of 278 children aged younger than 24 months evaluated for head injury. MAIN OUTCOME MEASURES: Presence of SF and/or ICA. RESULTS: Diagnoses at discharge included 227 minor head injuries, 39 isolated SF, 9 ICA with SF, and 3 isolated ICA. Children younger than 12 months had the highest incidence of SF/ICA (29%) vs 4% for children aged 13 to 24 months (P<.001). Seven percent of complications from SF/ICA resulted from falls 3 ft (0.9 m) or less [corrected]. Incidence of behavioral change, loss of consciousness, emesis, and seizures did not differ significantly between those with minor head injuries and those with SF/ICA. Scalp abnormalities were more common in children with SF/ICA (P<.001). Sixty-two percent of children with isolated SF and 58% of children with ICA had no history of loss of consciousness, emesis, seizure, or behavioral change. Ninety-two percent of children with isolated SF and 75% of children with ICA had normal levels of consciousness and nonfocal neurologic examinations at diagnosis. Among children who fell 3 ft or less (0.9 m) [corrected] and had no loss of consciousness, emesis, seizure, behavioral change, or scalp abnormality, none of 31 (95% confidence interval [CI], 0-0.10) children younger than 24 months and none of 20 (95% CI, 0-0.15) children younger than 12 months had SF/ICA. CONCLUSIONS: Both SF and ICA are common in children younger than 2 years evaluated for head trauma. Children younger than 12 months are at highest risk. Injuries resulted from relatively minor falls and occurred in alert, neurologically normal children. Clinical signs and symptoms were insensitive predictors of SF/ICA; however, a grouping of features (fall < or = 3 ft [0.9 m], no history of neurologic symptoms, and normal scalp physical examination results) identified a subset of children at low risk for complications.     

Hollow visceral injury and blunt trauma

BACKGROUND: The incidence of hollow viscus injury (HVI) after blunt trauma (BT) is variable, and differences between children and adults have not been well described. The purpose of this study is to determine the age-group-related incidence and characteristics of BT-associated HVI as well as the clinical markers and consequences of delayed diagnosis. METHODS: A 9-year trauma registry review of all patients with HVI. RESULTS: A large sample of patients (19,621) with BT were evaluated (2,550 < or = 14 years old; 17,070 > 14 years old). One hundred thirty-nine of 17,070 (0.8%) adults had HVI compared with 27 of 2,550 (1%) children. HVI occurred more frequently in the duodenum in children (11 of 27) compared with adults (17 of 139) (p < 0.05). Among patients with abdominal wall ecchymosis, 13.5% of children had HVI compared with 10.6% of adults. Delays in diagnosis of HVI occurred in 9 of 27 children compared with 10 of 139 adults (p < 0.0 5). Delayed diagnosis was associated with increased abdominal septic complications in both children (4 of 9) and adults (2 of 10) compared with diagnosis at presentation (p < 0.05). CONCLUSION: HVI occurs with a similar low frequency in both children and adults. Duodenal injuries are more common in pediatric BT patients. Abdominal wall ecchymosis is associated with increased HVI but is less predictive of HVI than previously described. Contrary to previous reports, delays in diagnosis are associated with increased morbidity.     

Refractive changes after pediatric intraocular lens implantation

PURPOSE: To report refractive changes after cataract surgery and intraocular lens implantation in infants and children. METHODS: In an ongoing prospective study, the refractive errors of all patients younger than 18 years undergoing intraocular lens implantation were determined at 6 weeks, 3 months, 6 months, and 1 year, and at least yearly thereafter. All patients with greater than 6 months of follow-up were included in the study. RESULTS: Eighty-three eyes of 81 patients were identified. Cataracts were traumatic in 32 eyes (38%) and developmental in 42 eyes (50%). At implantation, the mean (+/-SD) age was 6.3 +/- 4.6 years (range, 9 months to 17 years). The mean follow-up was 26.6 months (range, 6 months to 6.6 years). Patients 0 to 2 years old at the time of implantation demonstrated a mean myopic shift of -3.00 diopters during a mean follow-up period of 2.5 years. Patients 2 to 6 years old at the time of implantation demonstrated a mean myopic shift of -1.50 diopters in a similar follow-up period. Children aged 6 to 8 years experienced a mean myopic shift of -1.80 diopters during a mean follow-up period of 3.0 years, while children older than 8 years at the time of intraocular lens implantation experienced a mean myopic shift of -0.38 diopters during a mean follow-up period of 1.8 years. On average, the operated-on eye showed a greater mean myopic shift than the fellow eye. No statistically significant differences in refractive change were found in comparing amblyopic to nonamblyopic eyes, traumatic to nontraumatic cataracts, or primary to secondary intraocular lenses. CONCLUSIONS: Our data demonstrate a trend toward increasing postoperative myopia in pediatric patients undergoing intraocular lens implantation. This myopic shift is greatest in the younger age groups and persists until at least 8 years of age. There is much variability in the postoperative refractive changes, and predicting exactly when and where the refraction will stabilize for an individual patient is difficult.     

Clinical and treatment characteristics of children with attention-deficit/hyperactivity disorder in psychiatric practice

OBJECTIVE: To capture information about the clinical characteristics of, and treatments for, children with attention-deficit/hyperactivity disorder (ADHD) in psychiatric practice. METHOD: A mailed, self-administered questionnaire was sent to 81 practicing psychiatrists for them to complete on the next three consecutive patients aged 14 years and younger with ADHD seen during the 12-day study period. Information collected included the sociodemographic, clinical, and treatment characteristics of sampled patients. RESULTS: Patients in the study were predominantly white (85%), male (78%), and between 10 and 14 years old (58%). The most common ADHD subtype was combined/predominantly hyperactive (86%); 31% had no other comorbidity. Ninety-seven percent were receiving medications, with 49% receiving two or more. The single most common medication reported was methylphenidate (51% of patients) followed by clonidine (20%). Psychotropics other than psychostimulants were used in a majority of patients (55%). CONCLUSIONS: Psychiatrists, and child and adolescent psychiatrists in particular, see a more severely impaired and complex group of patients than would be expected of primary care providers. The treatment patterns of psychiatrists for these patients do not reflect the simpler treatments usually studied in clinical trials.     

Effect of helical CT on the frequency of sedation in pediatric patients

OBJECTIVE: We compared the use of sedation for helical CT examination of pediatric patients with that for conventional CT studies. MATERIALS AND METHODS: We retrospectively compared two 4-month periods of CT examinations that differed only in that conventional CT was routinely used in one period and helical CT was exclusively used in the other period. For these two periods, we compared the type and number of CT examinations, the sedation used (if any), and the age of patients who required sedation. RESULTS: We performed 1055 conventional CT examinations in 762 pediatric cancer patients. Of the 264 children who were 8 years old or younger, 107 had been sedated. In comparison, 1195 helical CT examinations were performed on 838 patients: of the 246 children 8 years old or younger, 51 received sedation. For both study groups, the mean and median age of the patients was 4 years old. The mean age of patients requiring sedation was 21 (conventional CT) or 20 months (helical CT); the median age of patients who required sedation was 2 years old for both study groups. Patients who were 8 years old or younger and who underwent helical CT required sedation 49% less frequently than such patients who underwent conventional CT. The most dramatic reduction occurred among patients who were 3 years old or younger (p < or = .004). CONCLUSION: Use of helical CT reduced the need for sedation among our pediatric patients. Fewer sedations may reduce the risk of complications, decrease disruption of the patient's normal daily activities, and improve patient throughout. The associated savings in personnel time and pharmaceutical costs can be redistributed.     

Substance abuse: infant and childhood outcomes

IOL implantation in childhood is still controversial. INTENTION: The purpose of this retrospective study was to evaluate functional results and complications in children after IOL implantation. METHODS AND RESULTS: Posterior chamber IOLs were implanted in 52 eyes of 45 children. Cataract extraction was necessary because of traumatic, congenital/developmental and secondary lens opacities. Nine IOLs were implanted in children between the ages of 1.9 and 4 years, 17 IOLs from 4 to 8 years and 26 IOLs in patients 8 to 14.3 years old. In 38 of the 52 eyes (73%) vision improved after the surgery. Fifty-four percent had an acuity of at least 0.5. The functional results of children more than 8 years old were superior to those of younger patients. Children with traumatic cataracts had better visual acuities than those with other types of cataract. Except for secondary capsular opacities (75%) that could not be prevented by performing a primary posterior capsulotomy or capsulectomy and iris capture (31%), postoperative complications were rare. CONCLUSION: Favorable functional results can be achieved by IOL implantation in children with cataracts. Many patients require secondary surgical procedures because of capsular opacities and iris capture.     

Impaired recovery of strength in older patients after major abdominal surgery

OBJECTIVE: This study compared changes in muscle strength after major elective abdominal surgery in young and old patients, and related these changes to body composition and nitrogen balance. SUMMARY BACKGROUND DATA: The breakdown of muscle protein, erosion of lean tissue, and negative nitrogen balance are characteristic metabolic responses to surgical illness. With a substantial loss of muscle mass typical of advancing age, the authors postulated that older patients would be weaker during acute surgical illness and less able to maintain muscle function and meet metabolic demands. METHODS: Active, community-dwelling individuals undergoing major abdominal procedures who were 70 years of age or older or 50 years of age or younger were studied. Total body water (TBW) was determined preoperatively by deuterium oxide dilution. Maximal voluntary handgrip, respiratory muscle strength, and visual analog pain scores were measured preoperatively and on postoperative days 2, 4, and 6. All urine was collected postoperatively for 7 days for determination of total nitrogen, creatinine, and cortisol. RESULTS: The young (age, 36 +/- 9 years [mean +/- standard deviation]; n = 20) and old groups (age, 77 +/- 5 years; n = 20) were similar regarding weight, sex distribution, nutritional status, surgical procedures and anesthesia, and postoperative urine cortisol values. Age group, time after operation, and interaction effects were significant for each strength variable (all p < 0.005 by analysis of variance). Older patients had lower preoperative strength (29% to 41%) and mean 24-hour urine creatinine (27%). Postoperative strength was decreased most markedly on postoperative day 2, with similar proportional changes in the two age groups but lower absolute levels in the older patients. The rate of recovery of strength was substantially less rapid and complete in older patients. Older patients had less postoperative pain and received much less parenteral narcotic than younger patients. Postoperative urine nitrogen was similar in each group. Recovery of strength was not related to malignancy, preoperative strength, muscle mass (urine creatinine), lean body mass (TBW), sex, malignancy, pain, or narcotic administration. CONCLUSIONS: Older patients are weaker preoperatively than younger patients; their strength falls to lower levels after surgery and their postoperative recovery of strength is impaired. The lesser preoperative strength of older patients is due in large part but not totally to diminished muscle mass. Their impaired postoperative recovery appears to be related to more acute factors, such as muscle energetics or substrate availability.     

Procedural results and long-term clinical outcomes following coronary stenting in perimyocardial infarction syndromes

STUDY DESIGN: A 15-year clinical follow-up of tuberculous lesions of the lumbosacral region. OBJECTIVES: To verify the hypothesis that the lumbar lordosis and the specific biomechanics of the lumbosacral region influence and alter the healing pattern and progress of the disease when compared with their effects in other regions of the spine. SUMMARY OF BACKGROUND DATA: An estimated 2 million or more patients have active spinal tuberculosis, and the global incidence of the disease is increasing. The involvement of the lower lumbar region and the lumbosacral junction is relatively rare, with few reports in English literature. METHODS: Of a total of 304 patients forming a part of a controlled clinical trial comparing two forms of therapy in spinal tuberculosis, 53 patients had involvement of L3 and below. The following data were studied in these patients: age at start of treatment, number of vertebra involved, vertebral body loss, progress of the angle of kyphosis, and anterior and posterior growth of the involved segment during a period of 15 years. Student's t test for independent samples was used for statistical analysis. RESULTS: The fourth lumbar vertebra was the most common vertebral segment involved, and the lumbosacral junction was affected in 12 patients. The average pretreatment kyphosis was 6.4 degrees and increased to 10.2 degrees at the end of 15 years. The average kyphotio angle per vertebral body loss was 4.9 degrees, far less than in the dorsolumbar region in which kyphotic angles of 27-30 degrees have been reported. Children younger than 10 years old differed in clinical appearance and progress compared with those older than 17 years. They not only showed more extensive involvement but also had more deformity with the same vertebral loss. Twelve patients less than 10 years old had an average involvement of 3.1 vertebral bodies and an average vertebral loss of 2.2 bodies. In comparison, the average number of vertebrae involved was 1.9 (P < 0.01) and the vertebral body loss was only 0.87 (P < 0.01) in patients older than 17 years. Also, the average kyphosis was 6.4 degrees compared with only 4.2 degrees (P < 0.01) in adults. In patients older than 17 years, there was no change after 2 years, by which time the collapse was complete. Four of 12 patients less than 10 years old, showed progressive kyphosis caused by continued growth of posterior parts of the body (i.e., sequestrated hemivertebrae). CONCLUSIONS: In tuberculosis of the lumbosacral region, the development of kyphosis is minimal in patients older than 17 years, when growth has already stopped, and deformity is expressed more as foreshortening of the trunk. Children younger than 10 years old have more severe involvement with increased tendency toward greater kyphosis. They are also prone to progressive deformity through the years when the anterior growth plates are destroyed. Surgery is indicated in this group to prevent greater deformity.     

Spread of HIV-1 to children in Cambodia

Beginning November 1, 1995, children under 5 years of age, who were admitted to Kantha Bopha Hospitals and who were suspected tuberculosis cases, were screened for human immunodeficiency virus 1 (HIV-1) using enzyme-linked immunosorbent assay (ELISA). By January 31, 1997, 9026 children, 83% of the under 5-year-olds admitted, had been tested; 290 (3.2%) were positive. Serum samples from 205 children of the 236 seropositive children under the age of 18 months were tested for p24 antigen; 51 (25%) were positive. Mothers of 173 of the seropositive children were tested for antibodies to HIV; 170 were positive, which suggests that the main mode of acquisition of HIV-1 in the children was vertical transmission. If HIV-1 infection occurred only in the 54 seropositive children older than 18 months and in the 51 children younger than 18 months with detectable p24 antigen, the calculated prevalence of HIV-1 in children under 5 years old who were suspected of having tuberculosis when admitted to Kantha Bopha Children's Hospitals would be 1.2%. If the 17% not included in the test were all negative, the prevalence would be 1%. This is an underestimate because some of the children not tested could be positive and because some of the children tested had indeterminate HIV status. HIV testing was extended to all children admitted to the hospital; 715 were younger than 5 years of age, 596 of whom were suspected of having tuberculosis, and 119 of whom were not. The seroprevalences for the 2 subgroups were 3.2% and 0.8%, respectively. None of the 369 older children was seropositive. In 1996, the World Health Organization estimated a seroprevalence of 1.97% in adults 15-49 years old in Cambodia, the highest among Asian countries. The blood bank at Kantha Bopha found 211 (6.6%) HIV-1 seropositives among 3197 donors in 1995 and 211 (7.5%) among 2834 donors in 1996. Similar figures were seen at the National Transfusion Centre in Phnom Penh. A 1996 survey in Cambodia found an HIV-1 seroprevalence of 40.9% in prostitutes and 1.7% in pregnant women. The vertical transmission of HIV-1 to children may increase because the virus appears to have been introduced recently to Cambodia; this is indicated by lack of seropositivity in children older than 5 years of age.     

Outpatient adenotonsillectomy. Is it safe in children younger than 3 years?

OBJECTIVE: To evaluate the safety of ambulatory adenotonsillectomy in children younger than 3 years. MATERIALS AND METHODS: The records of 102 children younger than 3 years who underwent adenotonsillectomy as an outpatient procedure were reviewed during a 3-year period. RESULTS: Ten patients (10%) required overnight hospital admission for an average of 1.4 days. Nine patients were admitted directly from the day-stay unit and 1 patient was admitted 48 hours after surgery. The reason for hospital admission was poor oral intake. None of the patients had postoperative bleeding or respiratory problems or required intensive care unit admission. CONCLUSION: The safety of ambulatory adenotonsillectomy depends on judicious selection criteria and can be performed in children younger than 3 years.     

Neurologic prognosis after cardiocirculatory arrest outside the hospital

OBJECTIVE: To detect clinical signs and times of evaluation able to identify patients with good neurologic prognosis after out-of-hospital cardiac arrest. EXPERIMENTAL DESIGN: Retrospective study with 6 months-2 years of follow-up. SETTING: General intensive care unit, from 1993 to 1995. PATIENTS: Twenty-three patients aged 18-80 years, admitted with coma after out-of-hospital cardiac arrest, who survived at least 24 hours, without concomitant neurologic disorders. INTERVENTIONS: Neurologic outcome classification in three categories: complete neurologic recovery (A), moderate to severe disability (B), death without regained consciousness (C); A and B groups of patients are considered together as a "good neurologic outcome" group. MEASUREMENTS: Evaluation of some neurological parameters (GCS, motor response to pain, spontaneous motility, cranial nerve reflexes, spontaneous breathing, seizures) 6 hours (t0), 24 hours (t1), 72 hours (t2) and 7 days (t3) after arrest. RESULTS: Patients with good prognosis are identified with 100% sensitivity from the following parameters: at t0 none; at t1 motor response to pain, GCS > 4, absence of seizures; at t2 the former parameters, spontaneous breathing, brain stem reflexes, normal pupils; at t3 all the former parameters and spontaneous motility. Specificity is greater than 50% only for motor response to pain and GCS > 4. CONCLUSIONS: It is mostly impossible to state a neurologic prognosis in the first hours after cardiac arrest. The single predictor with the most reliable prognostic value is motor response to pain which allows, if present, to identify all the patients with a good prognosis as early as 24 hours after arrest.     

Impact of clinical history and electrophysiologic characterization of accessory pathways on management strategies to reduce sudden death among children with Wolff-Parkinson-White syndrome

OBJECTIVES: This study sought to determine whether the clinical and electrophysiologic criteria developed in adults also identify children with Wolff-Parkinson-White syndrome at risk for sudden death. BACKGROUND: In adults with Wolff-Parkinson-White syndrome, a shortest RR interval <220 ms during atrial fibrillation is a sensitive marker for sudden death. However, because reliance on the shortest RR interval has a low positive predictive value, the clinical history has assumed a pivotal role in assessing risk. This approach has not been evaluated in children. METHODS: We retrospectively evaluated 60 children 相似文献